DOI: 10.14704/nq.2018.16.10.1861

Comparison of Double Inversion Recovery and FLAIR Sequences in Diagnosing Multiple Sclerosis Infratentorial Plaques

Gulhan Ertan, Barış Metin


Fluid–Attenuated Inversion Recovery (FLAIR) is the most commonly used sequence in routine practice for MS. Recent studies employ alternative sequences such as Double Inversion Recovery (DIR) in addition to conventional MRI techniques. In this study we compared these two sequences for their sensitivity in detecting infratentorial lesions in MS. A total of 24 patients with 3D DIR and 3D FLAIR sequences were included in this study. Plaques were classified according to their localization such as brainstem and cerebellar plaques. The relationship between number of infratentorial plaques and age, gender, MS type, disease duration, average annual number of attacks, cerebellar atrophy existence and EDSS score was also analyzed. DIR sequence detected higher number of lesions compared to FLAIR sequence in brainstem (59 vs 45 plaque in 24 cases) and cerebellum (50 vs 25 plaque in 24 cases). In detecting cerebellar lesions, superiority of DIR sequence compared to FLAIR sequence was statistically significant (p=0.049). Patients with longer disease duration had less cerebellar lesion load in FLAIR sequence at a statistically significant rate. Patients with longer disease duration and higher number of attacks had higher EDSS scores. There was no relationship between brainstem plaques number of cerebellum plaques and EDSS score. Comparing groups with and without cerebellar atrophy, cerebellar atrophy was also more frequent in patients with higher level of cerebellar lesion load in DIR sequence (p=0.028). Our findings suggest that DIR sequence is superior to FLAIR sequence in detecting cerebellar lesions. Cerebellar lesion load detected in DIR sequence was correlated to cerebellar atrophy. For this reason, especially during early period of disease, DIR sequence may be more useful than FLAIR sequence in distinguishing definite MS from clinical isolated syndromes and also for determining atrophy risk.


Multiple sclerosis, Double inversion recovery (DIR) sequence, Infratentorial plaque

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Bakshi R, Ariyaratana S, Benedict RH, Jacobs L. Fluid-attenuated inversion recovery magnetic resonance imaging detects cortical and juxtacortical multiple sclerosis lesions. Archives of Neurology 2001; 58(5): 742-48.

Bedell BJ, Narayana PA. Implementation and evaluation of a new pulse sequence for rapid acquisition of double inversion recovery images for simultaneous suppression of white matter and CSF. Journal of Magnetic Resonance Imaging 1998; 8(3): 544-47.

Calabrese M, De Stefano N, Atzori M, Bernardi V, Mattisi I, Barachino L, Morra A, Rinaldi L, Romualdi C, Perini P, Battistin L, Gallo P. Detection of cortical inflammatory lesions by double inversion recovery magnetic resonance imaging in patients with multiple sclerosis. Archives of Neurology 2007; 64(10): 1416–22.

Edwards SG, Gong QY, Liu C, Zvartau ME, Jaspan T, Roberts N, Blumhardt LD.Infratentorial atrophy on magnetic resonance imaging and disability in multiple sclerosis. Brain : A Journal of Neurology 1999; 122 (2): 291-301.

Elnekeidy AM, Kamal MA, Elfatatry AM, Elskeikh ML. Added value of double inversion recovery magnetic resonance sequence in detection of cortical and white matter brain lesions in multiple sclerosis. The Egyptian Journal of Radiology and Nuclear Medicine 2014; 45 (4): 1193–99.

Ertan G, Arici O, Ulus S, Metin B, Efficiency of Double Inversion Recovery (DIR) Sequence in the Evaluation of Supratentorial Cortical Lesions in Multiple Sclerosis. NeuroQuantology 2018; 16 (3): 23-29.

Gawne-Cain ML, O'Riordan JI, Thompson AJ, Moseley IF, Miller DH. Multiple sclerosis lesion detection in the brain: a comparison of fast fluid-attenuated inversion recovery and conventional T2-weighted dual spin echo. Neurology 1997; 49 (2): 364–70.

Geurts JJ, Roosendaal SD, Calabrese M, Ciccarelli O, Agosta F, Chard DT, Gass A, Huerga E, Moraal B, Pareto D, Rocca MA. Consensus recommendations for MS cortical lesion scoring using double inversion recovery MRI. Neurology 2011; 76(5): 418-24.

Geurts JJG, Pouwels PJW, Uitdehaag BMJ, Polman CH, Barkhof F, Castelijns JA. Intracortical lesions in multiple sclerosis: improved detection with 3D double inversion-recovery MR imaging. Radiology 2005; 236(1): 254–60.

Lassmann H, Brück W, Lucchinetti CF. The immunopathology of multiple sclerosis: an overview. Brain Pathology 2007; 17 (2): 210-18.

McDonald WI, Compston A, Edan G, Goodkin D, Hartung HP, Lublin FD, McFarland HF, Paty DW, Polman CH, Reingold SC, Sandberg-Wollheim M, Sibley W, Thompson A,van den Noort S, Weinshenker BY, Wolinsky JS. Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the diagnosis of multiple sclerosis. Annals of Neurology 2001; 50 (1): 121-27.

Minneboo A, Barkhof F, Polman CH, Uitdehaag BM, Knol DL, Castelijns JA. Infratentorial lesions predict long-term disability in patients with initial findings suggestive of multiple sclerosis. Archives of Neurology 2004; 61 (2): 217-21.

Moraal B, Roosendaal SD, Pouwels PJ, Vrenken H, Van Schijndel RA, Meier DS, Guttmann CR, Geurts JJ, Barkhof F. Multi-contrast, isotropic, single-slab 3D MR imaging in multiple sclerosis. European Radiology 2008;18(10): 2311-20.

Tubridy N, Barker GJ, Macmanus DG, Moseley IF, Miller DH. Three-dimensional fast fluid attenuated inversion recovery (3D fast FLAIR): a new MRI sequence which increases the detectable cerebral lesion load in multiple sclerosis. The British Journal of Radiology 1998; 71(848): 840-45.

Turetschek K, Wunderbaldinger P, Bankier AA, Zontsich T, Graf O, Mallek R,Hittmair K. Double inversion recovery imaging of the brain: initial experience and comparison with fluid attenuated inversion recovery imaging. Magnetic Resonance İmaging 1998; 16 (2): 127-35.

Vural G, Keklikoğlu HD, Temel Ş, Deniz O, Ercan K. Comparison of double inversion recovery and conventional magnetic resonance brain imaging in patients with multiple sclerosis and relations with disease disability. The Neuroradiology Journal 2013; 26(2): 133-42.

Wattjes MP, Lutterbey GG, Gieseke J, Träber F, Klotz L, Schmidt S, Schild HH. Double inversion recovery brain imaging at 3T: diagnostic value in the detection of multiple sclerosis lesions. American Journal of Neuroradiology 2007; 28 (1): 54-59.

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